Anna Schmidt, RN Carol Deets, RN

Writing measurable nursing audit criteria

Recent nursing literature abounds with discussions of the need for a sys- tematic, ongoing method for evaluat- ing nursing care. This is the first of four articles that deal with specific audit criteria for a patient population and the relation of audit to nursing practice.

When discussing the development of criteria for evaluating nursing care, authors frequently state that criteria

Anna Schmidt, RN, PhD, is assistant professor at Indiana University in In- dianapolis. She received her BSN, MSN, and PhD from the University of Texas School of Nursing at Austin. This article was written while Schmidt was a research associate at the Center for Health Care Research and Evalua- tion at the University of Texas School of Nursing.

Carol Deets, R N , EdD, is associate professor and director of the Center for Health Care Research and Evaluation at the University of Texas in Austin. She is a diploma graduate of Presbyte- rian Hospital School of Nursing in Charlotte, NC. She received her BS from Queens College in Charlotte and her MS and EdD from Indiana Uni- versity in Bloomington.

must be measurable. For instance, Aydelotte indicates that outcome criteria must be observable, quantifi- able, and useful,’ and Zimmer states, “A criterion must be appraisable.”* Criteria should be measurable whether they are structure, process, or outcome criteria.

Developing measurable criteria is not an easy task. Criteria are often written with primary concern for accu- racy of clinical content. Certainly, clinical content is of utmost impor- tance, but the accuracy of clinical data alone does not guarantee measurable audit criteria. What makes a criterion measurable? How can measurable criteria be developed?

This article provides ten guidelines for the construction of measurable criteria that the nurse or auditor may use in distinguishing between those patients who have successfully achieved a goal and those who have not. With each guideline, examples are given to illustrate its use. These guidelines are applicable for develop- ing outcome, process, and structure criteria. 1. Write the criterion so that the expected behavior is observable.

Incorrect The patient knows his

Correct The patient states the preoperative diet.

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reasons for his being NPO 12 hours before his surgery. (outcome)

The word “knows” in the incorrect example is not observable. How can one determine when someone knows something? Actions that are specific examples of knowing should be used to form the criterion statements. These actions, which represent knowing in the correct example, allow the nurse to observe the client’s behavior to see if he can meet the expected outcome.

For process and outcome criteria, action verbs are the key to stating precisely what observable behavior is expected. Action verbs specify exactly what behavior the nurse, patient, or family member is to perform. “Demon- strate,” “ambulate,” and “state” are examples of verbs that are observable and therefore measurable. 2. Write the criterion so that the expected task is clearly stated.

Incorrect The patient understands the results of her opera- tion.

Correct The patient states that tying her tubes means that she can never be- come pregnant. (outcome)

The word “understands” in the in- correct example is ambiguous because it is open to individual interpretation. For example, when two nurses deter- mine whether a patient understands the results of an operation, they may use different ways for rating the pa- tient’s level of understanding. One nurse may expect the patient to an- swer yes when asked if she under- stands the results of her operation; the other nurse may expect the patient to give specific examples of the surgery’s outcome. The two nurses’ exi)ectations differ greatly. The correct example clarifies what the patient is to do, and there is little possibility of two nurses

expecting different responses from the same patient. 3. Write the criterion 80 that it states, in specific terms, the desired behavior.

Incorrect The patient learns an ir- rigation technique for colostomy care.

Correct The patient irrigates his own colostomy according to the hospital’s estab- lished procedure. (out- come)

The incorrect example does state what the patient should learn but does not state the behavior desired as a result of the patient’s learning. The correct example clearly states in specific terms the action that the pa- tient is expected to perform. 4. Write the criterion so that it is free from irrelevant material.

Incorrect The patient states dos- ageW of take-home medi- cations that will be pre- scribed by the physician at discharge.

Correct Patient states correct dosage(s) of take-home medication(s). (outcome)

The incorrect example contains in- formation that is irrelevant and does not add to the meaning of the criteri- on. This added material only serves to confuse the reader. The patient’s be- havior, without extraneous informa- tion, is clearly stated in the correct example. 5. Write the criterion so that only one behavior is stated.

Incorrect The patient learns preop- eratively appropriate deep-breathing, coughing, and turning techniques.

Correct The patient demonstrates appropriate cough and deep-breathing tech- niques. (outcome)

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rite the criterion W so that it is realistic and achievable.

The patient demonstrates preoperatively appropri- ate turning techniques. (outcome)

The incorrect example, with three ideas in one criterion, is difficult to measure. If the criterion was charted as not met, the nurse or auditor would not know if the patient failed to achieve one, two, or all three parts of the criterion. Similarly, if the chart indicated that the criterion was met, could one assume that the patient achieved all three elements of the criterion? The correct example shows how the three ideas are broken down to form two separate criterion state- ments. As seen in the first correct criterion, there are occasions when what appears to be two ideas should be combined in one criterion. For exam- ple, coughing and deep breathing are usually considered to be one behavior since they are almost always per- formed together. The combination of two behaviors such as these is not a frequent occurrence. 6. Write the criterion using only standard, accepted medical ab- breviations.

Incorrect The patient expresses ANX.

Correct The patient ambulates independently TID. (out- come )

The incorrect example uses an ab- breviation that is not a standard, ac-

cepted abbreviation. Although it may seem trivial, not all nurses, even in the same hospital, may know that ANX means anxiety. The correct example uses a commonly accepted, well-known abbreviation, TID. Its meaning is standard throughout all institutions and for all health care pro- fessionals. 7. Write the criterion so that it in- cludes the person of whom the be- havior is expected.

Incorrect Dressing is changed PRN. Correct The nurse changes the

The incorrect example does not specify who is to perform the desired behavior. This criterion could be an outcome directed toward the patient or family member, or the criterion could be a process expected of the nurse. The correct example specifies that the nurse is the person who is expected to change the dressing. 8. Write the criterion so that it is realistic and achievable.

Incorrect There is one cardiac monitor for every five beds in the recovery room. There is at least one car- diac monitor in the recov- ery room. (structure)

The incorrect example is unrealistic for a small rural hospital and many moderate-size hospitals. Such hospi- tals do not need, and probably cannot

dressing PRN. (process)

Correct

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afford, a large number of cardiac monitors. In fact, patients who require monitoring are frequently transferred to a hospital that has the staff and the equipment to care for them adequate- ly. The correct example is stated so that it is realistic, ie, one monitor. Data can then be collected to see if more are needed. This criterion is far more achievable. Realistic and achiev- able are not to be equated with min- imally acceptable standards, but rath- er they represent a standard that is not totally ridiculous in view of the available resources. 9. Write the criterion in a positive form. ("he exception to this guideline is when complication criteria, such as required by the Joint Commission on the Accredi- tation of Hospitals, are to be in- cluded in the audit criteria.)

Incorrect The patient will not de- velop decubiti.

Correct The patient's skin is in- tact. (outcome)

The negatively stated incorrect example specifies only one complica- tion that should not occur. For exam- ple, the patient may still have skin breakdown even though he does not develop decubiti. If this criterion is met, there is still no indication that the skin is intact. The correct example represents an expectation of a higher level of care. Not only is the develop- ment of decubiti unacceptable, but so is a reddened area of skin. If the cri- terion is not met, one would further evaluate the chart to determine the actual condition of the skin. However, if it is met, it is immediately obvious that the skin is in good condition without further chart review. 10. Write the criterion specifically for the patient population so that only one or two exceptions to that criterion are likely to occur.

If one must provide many examples of a criterion before others can use it, that criterion is probably not as specific as it should be. In fact, a number of exceptions should serve as a cue to the possibility that a criterion needs to be more specific. Remember, audit criteria are developed for use in screening a large number of similar patients, not each individual patient with unique characteristics.

The use of these guidelines should enable the reader to translate clinical knowledge into measurable audit cri- teria. The correct and incorrect exam- ples provide models that demonstrate common mistakes that occur when generating criteria and ways in which, with the use of the guidelines, these mistakes can be corrected. Application of the guidelines provides the nurse a measure of assurance that the criteria developed are clear and concise and that the intended meaning is con- veyed.

There is some overlap among these ten guidelines. Even though writing a criterion in specific terms helps to make it clear, i t does not guarantee that it will be clearly stated. A crite- rion could be specific, clearly stated, and still not be observable. Since these guidelines are simple and appear to be no more than common sense, why bother with them in the first place? The truth of the matter is that only when each criterion is checked against each guideline are criteria likely to be measurable. Of course, the guidelines are not a guarantee. They cannot magically turn all poorly worded statements into measurable criteria. However, with practice and by rig- orously applying these guidelines, measurable criteria can be developed.

The evaluation of patient care and the accurate, specific recording of the results are becoming more important

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in health care professions today. Note* 1. M K Aydelotte, “Quality assurance programs

Therefore? must become in nursing: Definition and problems,” paper pre in criteria so that criteria sented at fie University of Illinois, Chicago, 1973. that reflect qual i ty nursing care are 2. M J Zimmer, “Guidelines for development of made explicit. 0 outcome criteria,” Nursing Clinics of North

America 9 (January 1974) 317-321.

Fewer health care professionals smoking Fewer health care professionals in the United States are smoking cigarettes, and more feel an obligation to “set a good example” for the general public. These are the findings of a 1975 study of the smoking habits and attitudes among US physicians, dentists, nurses, and pharmacists by the US Department of Health, Education, and Welfare (HEW).

The “Survey of health professionals: smoking and health, 1975,” shows that smoking by nurses has increased since 1969. In 1969, 37% of nurses surveyed smoked, compared to 39% in 1975. Twenty-one percent of physicians smoked cigarettes in 1975, as compared to 30% in 1967. Between 1969 and 1975, dentists who smoked dropped from 34% to 23% and pharmacists from 34% to 28%. Although more nurses smoke overall, the study revealed they smoke fewer cigarettes per day than the three other groups of health care professionals.

“Cigarette smoking is the most important preventable cause of premature death and illness in this country,” said Daniel Horn, director, National Clearinghouse for Smoking and Health, Center for Disease Control (CDC), Atlanta. “Twelve years ago, one of three physicians smoked cigarettes; now only one in five smokes. This continuing decline by those who know most about health is encouraging. It is also encouraging to see that health professionals are becoming more active in influencing the smoking habits of the general public.”

With the exception of nurses, health care professionals smoke less than the overall US adult population of smokers (34%). There are more smokers in the male-dominated professionemedicine, dentistry, and pharmacology-who smoke less than 15

cigarettes per day than in the general adult male population. Female nurses (98% of the nurses in the study) smoke fewer cigarettes per day than adult women smokers in the general population. Nurses lead the female population in quitting smoking. Smokers in all four health care professions smoke cigarettes with lower tar and nicotine contents.

believes potential bias may have been created in the survey because of the low response rate by nurses. The rate of nurses responding by mail and in telephone interviews was 49% compared to 67% for physicians, 73% for dentists, and 62% for pharmacists. ANA believes the HEW study “seems to assume . . . that the percentage of nurses who were unreachable had the same statistical profiles as those who did respond.” Nurses who were not reached, ANA suggests, “were more mobile and/or had changed their names. This group of nurses . . . is probably younger and apt to be more highly educated.”

Most health care professionals surveyed believe they should set a good example for their patients. They see cigarette smoking as a major cause of heart disease, cancer, and respiratory disease. Health care professionals also believe they should be more active than they have been in speaking to lay groups to convince them to stop smoking.

The study was conducted by the CDC National Clearinghouse for Smoking and Health in collaboration with the National Cancer Institute, Division of Cancer Control and Rehabilitation. A summary of the 1975 survey is available from the National Clearinghouse for Smoking and Health, Center for Disease Control, Atlanta, Ga 30333.

The American Nurses’ Association (ANA)

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